disturbances. There is great pain in the orbit, with displacement or fixation of the eyeball, oedema and redness of the eyelids. If these symptoms are associated with purulent discharge from the nose, nasal polypi, or hypertrophies, the existence of sinus suppuration may be presumed. In one out of five cases described by Hajek the empyema was closed, that is, no pus was seen in the nose. Sometimes the diagnosis may be rendered certain by clearing away the polypi and oedematous mucous membrane and then opening a cavity containing pus. In this way, not only may the diagnosis be made, but the abscess may be cured. In other cases exploration by the probe or finger after opening the abscess externally, will clear up the diagnosis. An abscess bursting through from the antrum. usually produces a swelling on the lower or inner wall of the orbit: from the ethmoidal cells on the inner side of the orbit, and from the frontal sinus in the upper or inner part. If a fistula has formed in connection with the frontal sinus, it is almost always found in the centre of the upper lid. Periostitis of the Upper Jaw. A periosteal abscess or fistula in connection with carious teeth, or following tooth extraction or other cause, may simulate antral suppuration. The absence of pus in the nose and of any communication between the antrum and the abscess, as determined by probing or syringing, will enable the diagnosis to be made. Acute osteomyelitis of the upper jaw is a curious affection usually met with in children, and has been frequently described as antral suppuration at an unusually early age. As late as the sixth year, the antrum is a very small cavity, and no instance of suppuration in it before this period has come under my notice, or has ever been truly verified. The cases of osteomyelitis are nearly all similar. An abscess forms, and bursts or is opened just inside the cheek above the canine or one of the adjacent teeth. Usually the abscess also points at the inner angle of the orbit, and the two openings communicate, as may be shown by syringing or by probing. The probe may pass beneath the periosteum or into the bone, and much bare carious bone is felt. Avellis was the first to point out the true nature of these cases. A dental cyst, especially if suppurating, may simulate antral suppuration. Enlargement of the alveolus of the upper jaw, or a swelling in the hard palate, should at once point to a dental cyst. Hajek states that he has never seen the upper jaw distended in antral suppuration: it is undoubtedly rare, and when it does occur the cavity bulges into the canine fossa, into the nose, or into the orbit, and never into the hard palate or alveolar process. The bulging of the superior wall is a most important sign, for it definitely indicates disease of the antrum, and can never Occur as 1 Thus Rudaux (Annales des Mal. de l'Oreille, etc., 1895, xxi. pt. 2, p. 239), reports a case in an infant of 3 weeks; D'Arcy Power (Brit. Med. Journ., 1897, ii. p. 808), a case at 8 weeks, Roure (Archiv. internat. de Laryngol., 1898, xi. p. 137), a case at 10 days of age; Mayer (Medical Record, 1901, August 10th), one at 24 years, etc. the result of a dental cyst. The outer wall of a dental cyst may per forate, and give rise to an abscess in the cheek, or an abscess or sinus may form in the hard palate or alveolar margin. On probing or syringing it will be demonstrated that there is no communication between this cavity and the antrum or nose. Of course it is possible that a dental cyst may burst into the antrum, one instance of this extremely rare occurrence having been privately reported to me. The following works may be consulted: KREBS. Archiv für Laryngol., 1898, iv. p. 224. Transillumination. HERYNG. Berlin. klin. Woch., 1889, xxvi. pp. 774, 798. VOHSEN. Berlin. klin. Woch., 1890, xxvii. p. 274. BROWN KELLY. Glasgow Med. Journal, 1892, xxxvii. p. 100. ROBERTSON. Journal of Laryngol., 1892, p. 62. ZIEM. Monatschr. für Ohrenheilk., 1893, xxvii. pp. 231, 261. Osteomyelitis of Upper Jaw. AVELLIS. Münch. med. Woch., 1898, xlv. p. 1433. CHAPTER XIX. TREATMENT OF CHRONIC SUPPURATION OF THE ACCESSORY SINUSES. INTRODUCTION. IN chronic suppuration of the accessory cavities of the nose it must at once be admitted that there is no possibility of a spontaneous cure, and that in every case surgical interference will be required. The objects to be aimed at in attempting the cure of a suppurating sinus may be enumerated as follows: (1) The treatment of any intranasal disease, and especially the removal of any cause of nasal obstruction such as polypus, so as to make. a free approach to the ostium of the affected cavity. (2) The removal of the retained discharge with or without opening the sinus. (3) The removal of the cause if still present. (4) The removal of all pathological conditions which are set up by the suppuration and tend to maintain it, such as granulations, polypi, carious or necrosed bone. And (5) when the above treatment fails to effect a cure, the adoption of means to prevent re-accumulation of the pus either by providing permanent free drainage, or by obliterating the cavity. Although the treatment is essentially surgical, every means, medicinal and otherwise, must be adopted to maintain or to improve the general health. A change of air, especially to a dry, bracing place, or to the seaside may be of the greatest benefit. General treatment may often render completely successful a smaller operation than would otherwise be necessary, or effect a cure when operative means alone have failed. Multiple Sinusitis. A point that must never be overlooked in the general management of these cases is that many sinuses are often simultaneously involved, and that a multiple sinusitis must be treated as a whole rather than as a series of isolated unconnected affections. This mistake is far too often made, possibly owing to the fact that the affections of each individual cavity are separately described in most books as if they were absolutely independent of each other; whereas, in reality, the various sinuses are closely associated, and the cure of one often depends upon the simultaneous cure of the others. Even the diagnosis depends to a large extent upon the result of treatment. When several sinuses are suppurating no absolute rule can be laid down as to the order in which they should be treated, but some general directions may be given for guidance. Order of Opening Sinuses. As already shown, it is usually possible to determine with some degree of accuracy which set of sinuses is affected; namely, whether the pus comes from the anterior set, that is the antrum, the anterior ethmoidal cells, and the frontal sinuses; or whether the posterior set, the posterior ethmoidal cells, and the sphenoidal sinus, are affected. If the anterior set of sinuses are involved and there is extensive polypoid degeneration or caries in the ethmoidal region, the ethmoidal cells should be first attacked, the polypi being removed and the ethmoidal region thoroughly curetted. Subsequently, if pus still continues to come from the nose, the antrum should be treated, and finally the frontal sinus. When, on the other hand, there is no indication as to which sinus is affected the antrum should be first explored and treated if found diseased; then the anterior end of the middle turbinate should be removed and any suspected anterior ethmoidal cells opened up; finally, the frontal sinus should be attacked. When the posterior set of cavities are involved, if, as occasionally happens in atrophic rhinitis, a view can be obtained of the ostium of the sphenoidal sinus, this sinus may be treated first, but in the large majority of cases it is necessary to commence the treatment by removing the posterior half or the whole of the middle turbinate. By this means the openings of the posterior ethmoidal cells and the ostium of the sphenoidal sinus are exposed to view: a complète diagnosis can then be made and further treatment carried out as required. In the rarer cases when the diagnosis cannot be made between affections of the anterior and posterior set of sinuses-and this, in my experience, has only occurred when numerous polypi are present, or when all the cavities are simultaneously involved-the first indication for treatment is the removal of the nasal polypi by the radical method already described (see p. 194). When this has been done a probable diagnosis can usually be made, but if not, the anterior set of sinuses should be first attacked seriatim, and subsequently the posterior. To give an example, in one case recently under my care, the left nasal fossa was full of polypi and granulations, from the midst of which much pus exuded. The polypi were removed with the snare. Subsequently, as extensive ethmoidal disease was disclosed, this region was thoroughly curetted, and the greater part of the ethmoidal cells opened. Whilst the patient was under the anaesthetic a small opening was made into the antrum through the alveolar border. On washing out the antrum it was found to contain pus; a plug was therefore inserted in the opening and regular irrigations instituted. When healing of the ethmoidal region had occurred pus in considerable quantity still continued to come down into the anterior part of the nose. A probe could be passed up into what appeared to be the frontal sinus, and its withdrawal was followed by a discharge of pus, this sinus therefore was opened externally, and, being found diseased, was obliterated. Nasal discharge still continuing, the sphenoidal sinus was explored and found to contain pus. After being irrigated for a few days without effect, the anterior wall of the sinus was removed. A general anaesthetic being given for this, a radical operation was performed at the same time upon the antrum, which still continued to secrete a little pus. Thus ultimately every sinus on the left side was opened, and drained or obliterated. The case is a typical and by no means rare instance; it well illustrates the order in which I think multiple sinus suppuration should be treated. The radical operation on the antrum was delayed to the last, as suppuration in this cavity often yields to simple treatment when the disease of the frontal and ethmoidal sinuses has been cured. The point on which too much stress cannot be laid is that it is necessary to open the cavities one by one until every source of suppuration has been found and removed. The treatment of each sinus presents somewhat different problems, and therefore must be considered separately. TREATMENT OF CHRONIC SUPPURATION IN THE MAXILLARY ANTRUM. When no External Complications are Present. In the first place suppuration in the antrum should be treated by irrigation, either through its natural opening or through a small puncture. These methods are very simple and comparatively harmless. They should be invariably adopted in the first instance, except in the rare cases in which severe symptoms are present pointing to caries or necrosis of the walls of the sinus, or in which there is distension of the cavity, or an external abscess or fistula communicating with it, or when it is probable that a foreign body is present;. in these circumstances a more radical proceeding is always necessary (see page 322). The chief methods practised are as follows: (1) Puncture and irrigation through the alveolus. (2) Puncture and irrigation through the inferior meatus. (3) Puncture and irrigation through the canine fossa. (4) Irrigation through the natural ostium. These methods are all similar in principle, for even when an artificial opening is made it is too small for drainage, and really only provides an easy means of cleansing the cavity at intervals, the pus re-accumulating between each washing. Frequently, however, this intermittent cleansing is sufficient to effect a cure. If the ostium of the sinus be patent, and the mucous membrane lining the cavity, and especially its ciliated epithelium, be not irretrievably damaged, the antrum may return to its original healthy condition. The particular method to be adopted depends on various circumstances. |